Healthcare Provider Details

I. General information

NPI: 1114403185
Provider Name (Legal Business Name): FAMILY FIRST SOLUTION COMMUNITY DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12280 SUMTER SQUARE DR W
JACKSONVILLE FL
32218
US

IV. Provider business mailing address

12280 SUMTER SQUARE DR W
JACKSONVILLE FL
32218-6125
US

V. Phone/Fax

Practice location:
  • Phone: 904-622-8684
  • Fax:
Mailing address:
  • Phone: 904-622-8684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. ASZLOYN NIKITA WAKEFIELD
Title or Position: CEO
Credential: ED.S.
Phone: 904-622-8684